Vestibular Migraine: Symptoms, Diagnosis & Treatment

Even if you don’t have a migraine disorder, chances are you’re aware of the painful and sometimes debilitating headaches it can cause.

However, headache isn’t the only symptom of migraine. In fact, some people with migraine rarely experience headaches. 

Vestibular migraine is a type of migraine that causes primary symptoms other than headache.

If you’ve ever had attacks involving intense periods of vertigo (a sensation of movement), imbalance, nausea, or vomiting, you may have had vestibular migraine.

In this article, I’ll explain the symptoms and causes of vestibular migraine, how to get diagnosed, and which treatments and preventive methods may help you find relief from your symptoms.

If you’re experiencing symptoms of vestibular migraine for the first time, reach out to your healthcare provider to discuss your options.

What is Vestibular Migraine?

Vestibular migraine (sometimes called migrainous vertigo, migraine-related dizziness, or migraine with prominent vertigo) is a type of migraine where people experience a combination of symptoms relating to balance, including vertigo or dizziness.

Vestibular migraine can cause a headache in some, but many people with vestibular migraine will not always experience headaches.

What Causes Vestibular Migraine?

Like traditional migraine, experts believe that vestibular migraine may run in families.

Another theory is that the condition is a result of overlapping pathways that modulate pain and inputs from a sensory system in the inner ear into the brain.

More research is needed to better determine the exact cause or causes of vestibular migraine and improve management of the disorder.

Who gets them?

It’s estimated that vestibular migraine may affect between 1-3% of the general population.

While it’s likely that the cause of vestibular migraine is partly genetic, there are other factors that can put one at a higher risk of developing vestibular migraine:

• Sex: As with traditional migraine, people born female are more likely to have vestibular migraine.

• Medical history: People with a history of migraine headache and childhood motion sensitivity, including motion sickness, are more likely to experience vestibular migraine. 

Potential triggers

Many of the triggers for migraine headaches can also trigger vestibular migraine. These triggers include:

• Poor sleep or insomnia
• Stress
• Dehydration
• Hormonal changes (particularly those associated with the menstrual period, perimenopause, and hormone replacement therapy)
• Certain foods (including chocolate, ripened or aged cheese, and red wine)
• Food additives (including MSG)

Symptoms

One of the primary symptoms of vestibular migraine is vertigo, a sensation of movement even when one is still.

This can include a feeling of spinning, dizziness, or swaying.

Vertigo can be debilitating, making it difficult to fulfill daily responsibilities and tasks. 

Additional symptoms of vestibular migraine can include:

• Sensitivity to smells
• Sensitivity to light and/or the sensation of light causing pain (photic allodynia)
• Sensitivity to touch on the head or face (cranial allodynia)
• Sensitivity to noise
• Nausea
• Vomiting
• Loss of balance
• Unsteadiness
• Sensitivity to motion
• Migraine headache (a severe, throbbing headache, often on one side of the head)
• Changes in hearing, including ringing, fullness, and pressure

Diagnosis

Unfortunately, diagnosis of the condition can be challenging, especially since many of the symptoms don’t always occur at the same time.

If you’re experiencing vertigo symptoms without headache, you’re likely to be seen by an ear, nose, and throat (ENT) specialist or neurotologist before speaking with a neurologist or headache specialist. 

Regardless of which specialist you speak with, there are generally four diagnostic criteria for vestibular migraine:

1. Having at least five episodes of symptoms
2. A present or past history of migraine headache
3. Experiencing vertigo or dizziness for a period between five minutes and three days
4. Having migraine headache or other migraine-related symptoms during at least half of your vertigo or dizziness episodes

Keep in mind that some of the symptoms of vestibular migraine could indicate another condition, including:

• Benign paroxysmal positional vertigo (BPPV)
• Méniére’s disease
• Transient ischemic attack (TIA), also known as a “mini-stroke”

Your provider may perform a vestibular function test to assess your inner ear balance organs and rule out suspicion of another vestibular disorder.

Importantly, both BPPV and Méniére’s disease can coexist with vestibular migraine, so one diagnosis doesn’t always rule out the other.

Treatment

Many of the standard migraine treatment options can also help in the treatment of vestibular migraine, with a particular emphasis on preventive medications, including certain antidepressants and some types of blood pressure medications. 

Other treatment options can include:

• Acute treatment medications: Over-the-counter (OTC) and prescription medications can help to soothe symptoms during an acute attack. These include non-steroidal anti-inflammatory drugs (NSAIDs), triptans ((including the almotriptan Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig), and anti-nausea  medications (including chlorpromazine, droperidol, metoclopramide, and prochlorperazine). Opioids should be avoided if you’re experiencing vestibular symptoms.

• Greater occipital nerve (GON) blocks: These injections contain small doses of local anesthetic and/or steroids. Delivered around the greater occipital nerve, your provider may recommend these injections as a preventive and/or short-term treatment option.

• Noninvasive vagal nerve stimulation (VNS): Emerging research suggests that noninvasive VNS may help to treat migraine headache as well as vestibular migraine. The procedure involves placing a small device over the neck which delivers an electrical pulse to activate the vagus nerve. However, further research is needed to determine the effectiveness of this approach.

• Additional medications: If you’re experiencing frequent attacks, your provider may recommend types of blood pressure medications (beta-blockers, calcium channel blockers), certain antidepressants (TCAs, SSRIs, or SNRIs), or nerve pain medication (topiramate). 

Prevention

As with traditional migraine, some lifestyle changes can help to manage the condition.

Implementing stress management techniques into your daily routine, sticking to a regular sleep and meal schedule, avoiding triggers, and exercising regularly may help to keep your symptoms at bay. 

There are also some medications that can help to prevent symptoms.

Reach out to your provider to discuss whether or not any of these options may be right for you.

When to See a Doctor

If you’re experiencing symptoms of vestibular migraine and/or migraine headaches, reach out to a provider or neurologist to discuss your diagnosis and treatment options.

Getting diagnosed is the first step in learning which treatment and preventive options may work best for you. 

Keep in mind that your provider may ask you to start a diary in which you note when you experience symptoms and which factors, if any, may be triggering them.

If you experience any of the below symptoms, be sure to seek immediate medical attention: 

• Fever
• Nausea
• Shortness of breath
• Weakness in the body
• Confusion
• Double vision
• Stiff neck
• The “worst” headache of your life
• A headache prompted by a head injury
• A severe and sudden headache if you’ve never, or rarely, experience headaches

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